PubMed Health⌕ Search

Biomedical subjects

I Bowler

Publications and source records attributed to I Bowler.

At least 19 recordsLinked to original sources
PubMed2001

Derivation and validation of guidelines for stool cultures for enteropathogenic bacteria other than Clostridium difficile in hospitalized adults.

CONTEXT: The yield of in-hospital stool cultures performed more than 72 hours after admission is low, and a commonly used policy dictates that laboratories reject these cultures to save costs. However, enteropathogenic bacteria other than Clostridium difficile (EPB) may cause nosocomial illness that would be missed by use of such a "3-day rule." OBJECTIVE: To develop guidelines for hospital use of stool cultures that are sensitive to clinically relevant cases of sporadic and epidemic nosocomial diarrhea. DESIGN: Five-part study that incorporated a derivation sample based on retrospective chart review and a prospective cohort study (including cost savings analysis), and a validation sample based on retrospective chart review. SETTING: Four European academic health care centers. PATIENTS: Derivation sample: 1735 adult inpatients from whom 3416 stool cultures were obtained during a 19-month period (1995-1997) and 68 adult inpatients for whom EPB were grown from stool cultures during a 10-year period (1988-1998); validation sample: 65 patients with sporadic isolation of EPB (1993-1998), 56 patients involved in 2 nosocomial Salmonella outbreaks (1992 and 1997), and 330 patients who had stool cultures performed (1998). MAIN OUTCOME MEASURE: Performance of derived criteria in detecting pathogenic bacteria and outbreaks and reducing total number of stool cultures performed. RESULTS: Stool cultures grew EPB in 3.3% of samples obtained </=72 hours after admission and 0.5% of samples obtained thereafter (P<.001). Isolation of EPB >72 hours after admission was not associated with clinical symptoms or signs but was associated with community-acquired diarrhea (24%), age 65 years or older with preexisting comorbid disease (25%), neutropenia (13%), HIV infection (10%), and nondiarrheal manifestations of enteric infections (16%). Twelve percent were asymptomatic carriers. These characteristics were used to create criteria for selecting patients for whom stool cultures would be indicated. These criteria were applied post hoc to a series of 1025 stool cultures; the number of stool cultures would have been reduced by 52% and no clinically significant cases would have been missed. Annual savings to a 355-bed institution would be approximately $7800 for reagent costs and 75 hours of technician time. In the validation samples, only 2 patients of 65 who had EPB would not have been identified, and neither required treatment. If the 3-day rule had been applied, 52 cases would not have been identified, 28 of which required antibiotic treatment. CONCLUSION: Our modified 3-day rule for use in selecting cases for stool culture is sensitive to sporadic and epidemic cases of nosocomial diarrhea in hospitalized adults.

Adult↗
PubMed2000

How do general practitioners choose their practice? Preferences for practice and job characteristics.

OBJECTIVES: To investigate the strength of preferences for practice and job characteristics among recently appointed general practitioners (GPs) in south-east England. METHODS: Conjoint analysis based on a postal questionnaire survey of all 293 GPs who joined a new practice between April 1997 and March 1998 in London, Essex and Hertfordshire. GPs were presented with descriptions of practices in pairs, which varied systematically for key characteristics, and asked to indicate their preferred practice in each pair. RESULTS: The response rate was 58.7%. The most important influence on GPs' choice of practice was aversion to location in an area of high deprivation. They were more likely to choose a practice that: had an extended primary health care team; offered opportunities to develop outside interests; and offered them higher income, shorter working hours and smaller list sizes. The model generated estimates of the strength of these preferences. For example, GPs would require additional income of just over 5000 Pounds per annum to work in an area with a high proportion of deprived patients. CONCLUSIONS: Potential policy interventions to attract GPs to under-served areas include increasing their level of remuneration, providing opportunities to develop outside interests and ensuring that practices have a primary health care team.

Attitude of Health Personnel↗
PubMed1997

Physical activity promotion through primary health care in England.

BACKGROUND: There is increasing research supporting the argument for a beneficial link between physical activity and health maintenance and, in the past five years, this has led to a growth in physical activity promotion schemes involving primary health care. AIM: To document and critically examine the extent and nature of physical activity promotion in general practice in England. METHOD: A postal survey to all family health services authorities and primary care facilitators was conducted to identify existing and planned activity promotion schemes involving primary health care. Telephone interviews with leaders from 50 selected schemes and further detailed case studies of 11 schemes provided descriptive information of the nature of physical activity promotion. RESULTS: The initial phase revealed 157 existing schemes and a further 35 planned schemes. Two basic models of physical activity promotion were identified that were distinguishable by the primary location of the management of the patient. Practice-managed interventions (32%) involve on-site counselling to change the behaviour of patients. Leisure centre-managed projects (68%), sometimes termed 'exercise by prescription' or 'general practitioner referral for exercise' schemes, involve the identification of suitable patients and their referral to 10- to 12-week-long leisure centre based exercise induction courses. The projects in the planning stage were all of the latter type, indicating this as the favoured model. Although such schemes were generally successful in attracting patients, in all cases they involved less than 1% of the patient base from which they were drawn. CONCLUSION: There is evidence of successful recruitment, increased short-term physical activity and fitness, and improvements in the well-being of patients. However, schemes are inadequately resourced for rigorous long-term evaluation; therefore, conclusions regarding the cost-effectiveness of the two models are not possible.

England↗
PubMed1995

Health promotion in primary health care: the situation in England.

National policy, including changes to the management of the National Health Service, is intended to increase the amount of primary and secondary prevention in primary health care in England. The growth of financial power of general practitioners makes them key decision-makers in planning and delivering health promotion. The vast majority of people in contact with their family doctor could benefit from making appropriate lifestyle modifications. However, the level and quality of health promotion activity in primary care is variable, with many patients not receiving interventions. A review of research indicates that both skepticism about the relationship between behaviour and risk factor, and lack of confidence in efficacy of health promotion in changing patient behaviour act as barriers to general practitioners taking on more health promotion activity. For prevention work to increase, therefore, general practitioners require more evidence of effective replicable interventions, and appropriate training on the design and implementation of programmes. The role of the Health Education Authority, the national agency for health promotion in England, in meeting these needs is described. The paper also includes a brief discussion of evaluation methods for assessing the success of health promotion interventions.

Family Practice↗
PubMed1994

The chest radiograph in cystic fibrosis: a new scoring system compared with the Chrispin-Norman and Brasfield scores.

BACKGROUND: Scoring systems for the chest radiograph in cystic fibrosis are used to compare patients and different treatment regimens, and to monitor respiratory disease in individual patients. The Northern chest radiograph score was designed to allow one person to assess the radiological features of lung involvement in cystic fibrosis in as simple, rapid and equally reproducible manner as the established Chrispin and Norman, and Brasfield scoring systems. METHODS: Forty five chest radiographs were scored by 10 physicians with a special interest in cystic fibrosis according to the Brasfield and Northern methods, and by five pairs of physicians according to the Chrispin-Norman criteria. Three individuals and two pairs rescored the radiographs after an interval of 3-5 months. The Northern score was performed with and without a lateral view, using the original posteroanterior radiograph. RESULTS: The Northern score showed a better agreement between observers for the ranking of the radiographs. It was equally well related to respiratory function tests, the Shwachman-Kulczycki score of overall clinical status, and in its discrimination between different radiographs as the other two scoring systems. The Northern score performed equally well with or without a lateral film. CONCLUSIONS: The Northern system fulfils the requirements of a chest radiograph score more successfully than the Chrispin-Norman or Brasfield systems, and does not require a lateral film.

Cystic Fibrosis↗
PubMed1993

Microbiological lung surveillance in mechanically ventilated patients, using non-directed bronchial lavage and quantitative culture.

We surveyed bronchial microflora by alternate-day, non-directed bronchial lavage (NBL) in 150 patients requiring mechanical ventilation on an intensive care unit. This simple technique uses a 20 ml non-bronchoscopic lung lavage, then quantitative bacterial culture. NBL bacteriological findings were identical to those obtained by same-day bronchoscopic broncho-alveolar lavage on 16/20 occasions. Using serial NBLs, the bronchial bacterial population was characterized during 65 episodes of pneumonia defined by clinical and retrospective criteria. Mean bacterial colony counts increased significantly during the 2 days preceding the clinical onset of pneumonia, from < or = 10(3) cfu/ml to > or = 10(5) cfu/ml (p < 0.05). In 51 patients showing a clinical response to antibiotic treatment, mean colony counts fell significantly after antibiotic initiation (p < 0.05). By contrast, in 14 patients who showed progressive clinical deterioration or relapse, there was no significant fall in NBL counts, and serial NBLs revealed antibiotic resistance or superinfection. The surveillance data altered clinical management in 42% of patients. Positive NBLs guided the choice of antibiotics, whilst negative NBLs encouraged the withholding of antibiotics, or detection of alternative pathology. We propose routine bacteriological lung surveillance of mechanically ventilated patients using this simple, inexpensive and safe technique.

Anti-Bacterial Agents↗
PubMed1993

Prospective surveillance of neonatal meningitis.

Neonatal meningitis is a serious problem with a high mortality and frequent neurological sequelae. The incidence of neonatal meningitis was calculated and the aetiology, clinical and laboratory features, and the treatment of cases recorded prospectively over a 7 year 8 month period was documented. It was further investigated whether secondary meningitis had occurred after lumbar puncture. The estimated incidence of bacterial, viral, and fungal meningitis was 0.25, 0.11, and 0.02 per 1000 live births respectively. There were eight cases of early onset meningitis (seven definite, one probable) and group B streptococci accounted for six (75%) of these. Blood cultures were negative in only one of seven cases of definite early bacterial meningitis. Of the 15 late onset cases, Gram negative organisms accounted for six of the seven bacterial cases. The overall mortality was 26%. Of the 11 survivors of bacterial meningitis, three (27%) had significant neurological sequelae at follow up (between three months to three years later). As in the first 48 hours after birth an initial blood culture is unlikely to be negative if bacterial meningitis is present, lumbar puncture can be deferred if the procedure might exacerbate respiratory distress. Although approximately 1880 infants had a lumbar puncture during the review period, only one case of meningitis was found where it was possible that lumbar puncture in a bacteraemic infant may have caused meningeal infection. The incidence of this potential complication must therefore be low.

Birth Weight↗
PubMed1993

Value of cerebrospinal fluid examination in the diagnosis of meningitis in the newborn.

Between 1 October 1988 and 30 September 1991 the results of all 896 cerebrospinal fluid examinations from 736 neonates were correlated with clinical diagnosis, treatment, and outcome. The prevalence of fungal or bacterial meningitis in babies requiring lumbar puncture was only 0.95%. Gram staining had a sensitivity of 68% and a positive predictive value of only 46% for the diagnosis of meningitis. Primary cultures directly onto agar plates had a sensitivity of 81% and positive predictive value of 46%. Broth enrichment cultures did not improve sensitivity and were frequently found to be false positive. Empirical treatment should not be altered unless more than a few organisms are seen on Gram staining. Primary cultures are adequate for the diagnosis of fungal and bacterial meningitis. Enrichment cultures should be performed only when the Gram stain and/or cell count suggests meningitis is likely. Clinicians should be aware that diagnostic tests performed in populations with a low prevalence of disease are likely to generate many false positive results and have a low positive predictive value.

Bacteriological Techniques↗
PubMed1989

A survey of private nursing home residents in Weston Super Mare.

A representative sample of 351 patients in Private Nursing Homes in Weston Super Mare was surveyed with regard to their origins, admission assessment and continuing care, with particular reference to the nature of medical review during their residency. The results suggest inadequate medical care especially for 'imported' patients and those admitted for psychiatric reasons.

Aged↗